Topic: Borderline Personality Disorder

Suggested key questions:

What is the efficacy and comparative effectiveness of pharmacological and non-pharmacological treatments for affective dysregulation symptoms, including impulsive-behavioral dyscontrol, in adults with borderline personality disorder?

What are the harms from pharmacological and non-pharmacological treatments for affective dysregulation symptoms, including impulsive-behavioral dyscontrol, in adults with borderline personality disorder?

What patient characteristics predict the effectiveness and harms of pharmacological and non-pharmacological treatments for affective dysregulation symptoms, including impulsive-behavioral dyscontrol, in adults with borderline personality disorder? Examples of relevant patient characteristics would include demographic factors (e.g., age, sex, race/ethnicity, socioeconomic status), time since illness onset, prior treatment history and degree of treatment resistance, co-occurring disorders (e.g., medical, substance use and other psychiatric disorders), and history of trauma or abuse.

Non-pharmacological treatments would include psychotherapy, psychoeducation and other psychosocial interventions, including multi-component programs. It would also include non-pharmacological somatic therapies such as electroconvulsive therapy or transcranial magnetic stimulation, if relevant studies have been conducted.

Outcome measures of interest would include improvements in social/occupational functioning, improvements in health related quality of life, the proportion of patients who experience a response in target symptoms (including affective dysregulation and impulsivity), the magnitude of reduction in target symptoms, reductions in hospitalizations, reductions in self-harm including suicide and suicide attempts, reductions in agitation or aggressive behaviors, changes in the status of co-occurring disorders, and the proportion of patients who experience key harms with a given treatment. (See recent AHRQ protocols on bipolar disorder, major depressive disorder and schizophrenia for other outcomes and harms to be considered with psychotropic medications and non-pharmacological interventions.)

Borderline personality disorder has been reported to affect 1-3% of the population (Lieb et al. Lancet. 364(9432):453-61, 2004; Lenzenweger et al., Biol Psychiatry. 62(6):553-64, 2007; Tomko et al. J Pers Disord. 28(5):734-50, 2014). Rates in clinical samples are even higher (Lieb et al. Lancet. 364(9432):453-61, 2004; Tomko et al. J Pers Disord. 28(5):734-50, 2014). In one recent study of high-utilizers of psychiatric services, 20-40% of individuals had a clinical diagnosis or met DSM-IV criteria for borderline personality disorder (Comtois and Carmel J Behav Health Serv Res. 43(2):272-80, 2016). Borderline personality disorder is also associated with a significant risk of suicide (Chesney et al., World Psychiatry. 13(2):153-60, 2014; Qin J Psychiatr Res. 45(11):1445-52, 2011; Doyle et al. BMC Fam Pract. 17:106. 2016; Tomko et al. J Pers Disord. 28(5):734-50, 2014). Self-injury is common among individuals with borderline personality disorder (Lieb et al. Lancet. 364(9432):453-61, 2004) and carries its own morbidity. Rates of intimate partner violence may also be increased in the context of a borderline personality disorder diagnosis (Gonz lez et al., BMC Psychiatry. 16:180, 2016). Overall, borderline personality disorder is associated with significant psychosocial impairment (Zimmerman et al. Br J Psychiatry. 207(4):334-8, 2015; Tomko et al. J Pers Disord. 28(5):734-50, 2014) and substantial mental and physical disability (Zanarini et al., J Pers Disord. 23(4):346-56, 2009) as well as high rates of co-morbidity with other psychiatric conditions (Friborg et al., J Affect Disord. 152-154:1-11, 2014; Grant et al., J Clin Psychiatry. 69(4):533-45, 2008). Comorbid mood, anxiety and substance use disorders are particularly common. The presence of borderline personality can have a negative impact on the treatment outcomes for the co-occurring disorder (Grilo et al. J Clin Psychiatry. 71(12):1629-35, 2010; Skodol et al. Am J Psychiatry 168(3):257-64, 2011).

Given the substantial morbidity, mortality, disability and health service utilization associated with the presence of borderline personality disorder, an up-to-date evidence-based review of the efficacy and comparative effectiveness of borderline personality disorder treatments would inform development of clinical practice guidelines aimed at optimizing clinical interventions and patient outcomes.

The results of the comparative effectiveness review will be used to inform development of a practice guideline on the treatment of individuals with borderline personality disorder. The most recent practice guideline of the American Psychiatric Association was published in 2001, with an updated discussion of subsequent literature in 2005. Although a review of all aspects of borderline personality disorder treatment would be of benefit to the field, this request focuses on symptoms of affective dysregulation (including impulsive-behavioral dyscontrol), which are most likely to be associated with negative psychosocial and health outcomes.

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Professional society; developer of clinical practice guidelines

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American Psychiatric Association

Please tell us how you heard about the Effective Health Care Program

The American Psychiatric Association has been aware of the Effective Health Care Program for a long time. We are now using the systematic reviews produced by the Effective Health Care Program for guideline development and we track the status of Effective Health Care Program projects that are under development through e-mail alerts and frequent use of the Effective Health Care Program website.